Cosmetic Eyelid Surgery in Beverly Hills – Dr. Guy Massry
18May/110

Beverly Hills Blepharoplasty – How Eyelids Age

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For years when patients came to see cosmetic surgeons for eyelid surgery (blepharoplasty, canthoplasty, ptosis repair, fat grafting, fat repositioning, etc) they were counseled on how surgery could remove the excess skin and bags and get rid of wrinkles.  The thinking was that gravity made the eyelids and face sag and that cutting out eyelid skin and fat and lifting tissue (traditional blepharoplasty) was the answer.  Well we have found that often times this kind of blepharoplasty surgery makes patients look funny, gaunt, pulled and “done.”  It just doesn't look natural.  Why is this?  In the last decade or so we have learned that one of the main reasons we look aged and tired is loss of volume (fat) from our faces.  This causes skin and muscle to fall and collapse.  It is the same thing that happens to grapes as they turn into raisins.  With this in mind, when approaching eyelid surgery like blepharoplasty, canthoplasty and ptosis repair, we have concentrated very hard on techniques which replace volume in the face whether they be gel fillers (Restylane, Perlane, Juvederm) , or our own fat (fat grafting and fat repositioning).  This has revolutionized how we approach cosmetic blepharoplasty surgery.  We no longer emphasize subtractive blepharoplasty surgery (where all we do is remove tissue); but rather focus on replacing what is lost.

This concept of volume loss with age is most apparent around the eyes.  The upper and lower lids are supported by muscle, fat and bone.  With age the fat shrinks, the muscle weakens and bone is resorbed (lost like bone loss in the body with osteoporosis).  With this tissue loss the lids lose support and sag.  This leads to bags, dark circles, puffiness, hollows, and wrinkles.  The sun damage to the skin accentuates the appearance by causing the skin to lose collagen and elastin (the stretchy material in the skin that allows it to snap back into place like a rubber band).

We now believe that replacing this lost volume during cosmetic blepharoplasty is the most important feature of restoring youth.  Rather than tissue reduction during surgery, we emphasize tissue addition (fat grafting, fat repositioning, and the use of fillers like Restylane, Juvederm and Perlane).

Below is an example of a woman before (left) and after (right) blepharoplasty surgery with the addition of fat grafting and fat repositioning of the depressions around the lower lids.  Note the significant improvement in appearance.

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14May/110

Revisional Eyelid Surgery – Fixing the Canthus

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Webbing of the lateral canthus (where outer upper and lower lids meet) is called a canthal web.  Normally the lateral canthus consists of an almond shaped angle.  When webbing occurs, skin obscures the angle and the canthal angle resembles a duck's foot which is normally webbed.  This causes both aesthetic disfigurement (it is not attractive), and a functional deficit (the web blocks vision on side gaze).

The best way to treat a canthal web is to avoid allowing it to develop.  These webs occur in a variety of situations.  I have had them sent to me form correction when:

1.  Upper and lower lid surgery has been performed together and the outer portions of the upper and lower lid incision are too close to each other.

2. When a canthoplasty (lower lid tightening) has been added to surgery

3. When an infection has occurred after surgery

4. When a hematoma (bleed) has occurred after surgery

Canthal webs occur because there is a relative deficiency of skin in the vertical as compared to the horizontal plane.  They are surgically corrected by a variety of micro-skin flaps.  Most plastic surgeons avoid addressing canthal webs as they are difficult to correct and can lead to significant scaring.  I have been referred numerous webs over the years and have developed a reliable means of correcting them.  I recently published a peer reviewed manuscript titled "Cicatricial Canthal Webs."  It will appear in our society journal "Ophthalmic Plastic and Reconstructive Surgery" later in the year.

Below is an example of a lateral canthal web repair.  On the left the web is present on a patient who had blepharoplasty surgery.  Note how the webbed skin blocks vision on side gaze. On the right is the patient 6 months after repair.  I would be happy to see you, or anyone you know who needs assessment and treatment for a canthal web, or for any revisional eyelid procedure

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12May/110

Lower Lid Fat Grafting and Fat Repositioning

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Lower eyelid rejuvenation has undergone a tremendous evolution in the last decade.  There has been a paradigm shift from fat excision to fat preservation.  This has recreated youth rather than advancing the aging process which typically involves fat loss from the eyes and face.

There are two ways to augment volume (filling depressions with fat) in the lower lids. One technique is called fat repositioning. This involves translocating eyelid fat which is prominent to areas where it is deficient (depressions, grooves and hollow areas).  This is an incisional surgical technique which I perform from the inside of the lid to prevent external scars.  I have found this procedure to be reliable, reproducible and to consistently yield excellent results.

Below is an example of a patient who underwent lower lid blepharoplasty with fat repositioning (before – left/ and after - right).  Note the reduction of lower lid “bags,” and filling of grooves underneath.

The other fat filling procedure is called fat grafting.  In this instance fat is taken from a different area of the body (ex. abdomen) and injected (grafted) into the depressed areas around the lower lids.  In experienced hands this also yields excellent results.

Below is another patient.  She had fat grafting to the hollows at the junction of the lower lids and cheek. Note the significant improvement in appearance (before – left/ and after - right).  Fat grafting does not require eyelid incisions but the results can be less predictable than fat repositioning.

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10May/110

What Is A Canthoplasty?

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One of the major complications of lower eyelid blepharoplasty is a retracted (pulled down) lower eyelid.  This leads to a change in the shape of the eye, a rounded outer corner to the eye, and sometimes a “wide-eyed appearance.” The goal of any cosmetic blepharoplasty is to improve appearance in a natural way – “NOT” to change ones look.

How can this be accomplished.  Firstly, performing surgery from the inside of the lid, “a transconjunctival blepharoplasty,”reduces the chance of an altered shape to the eye.  The surgeon must be well versed in this procedure to perform it correctly.  Next, a preoperative assessment of eyelid laxity (looseness), and excess skin must be made.

If the lid is loose, or if there is skin to be excised, the lid may need to be tightened for support.
The lid tightening procedure is called a canthoplasty. This procedure may be a necessary step in lower lid blepharoplasty to prevent altering the shape of the eye.  An off-shoot of the canthoplasty procedure is called a canthopexy.  This is also a lid tightening- just a less aggressive one.  It is indicated when the lid requires less support.

Canthoplasty surgery is a very specialized procedure which should only be performed by cosmetic surgeons with significant experience with eyelid surgery.  If performed incorrectly the results can be disastrous.  Before undertaking this surgery make sure the surgeon has experience in this area.

Dr. Guy Massry has specific expertise in canthoplasty and canthopexy surgery.  Please refer to his photo gallery, or below (left - before surgery, right - after surgery), for examples of lower lid blepharoplasty procedures which included canthoplasty and canthopexy.

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10May/110

Revisional Blepharoplasty – The Retracted Lower Lid

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A retracted lower lid is one that is pulled down. When the lower lid is retracted it causes cosmetic disfigurement and potentially dry eye symptoms (irritation, scratchy feeling and redness). This can occur after cosmetic lower lid surgery and lead to very unhappy patients. This problem can be corrected by an eyelid specialist. The best way to avoid it is to have surgery performed by a surgeon with significant experience with eyelid surgery. Below is an example of a case sent to Dr. Massry for the repair of a retracted lower lid. Note the improvement in lid position from before (left) to after (right) surgery.

 

 

 

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9May/110

New Surgical Technique to Improve Outcomes of Upper Blepharoplasty Surgery

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Dr Guy Massry, MD (Ophthalmic Plastic Surgery) of Beverly Hills, California has introduced a new surgical technique to improve outcomes in upper eyelid blepharoplasty surgery.

The novel technique demonstrates how to preserve eyelid fat during upper blepharoplasty surgery to prevent postoperative hollowing of the eyelids.  This is an important addition to our evolving understanding of maintaining eyelid fat during surgery to prevent a sunken appearance after surgery.  This concept has gained wide acceptance with lower lid surgery, but until now has not been elaborated well in upper lid surgery.

Traditional upper blepharoplasty is a subtractive form of surgery that involves the excision of variable amounts of skin, muscle, and fat from the eyelid. The goal of surgery is to improve field of vision and/or appearance. While surgical debulking of the eyelid may improve appearance early on, the removal of tissue inherent to this process (especially fat excision) can contribute to a hollowed appearance with an associated deep and sunken appearance of the upper eyelid. This skeletonized look may be eliminated or reduced by preserving and repositioning a prominent nasal (inner) fat pad, if present, to the central upper eyelid.

The article is featured in the peer reviewed journal Ophthalmic Plastic & Reconstructive Surgery - the primary periodical of the society.

Link:

http://journals.lww.com/op-rs/Abstract/publishahead/Nasal_Fat_Preservation_in_Upper_Eyelid.99710.aspx - the full article can be viewed by opening the article PDF under article tools

This recent innovation, which Dr. Massry has also presented at scientific medical meetings, is born out of a continuing effort by Dr Massry to improve the field of Ophthalmic Plastic & Reconstructive Surgery. Dr. Massry is also active making comprehensive information available to anyone considering ophthalmic plastic surgery through his website and social network pages. Please visit www.drmassry.com .

6May/110

Lower Lid Ectropion

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An ectropic lower lid is one that is turned out.  When the lower lid is ectropic it causes cosmetic disfigurement and potentially dry eye symptoms (irritation, scratchy feeling and redness).  This can occur after cosmetic lower lid surgery and lead to very unhappy patients.  This problem can be corrected by an eyelid specialist.  The best way to avoid it is to have surgery performed by a surgeon with significant experience with eyelid surgery.  Below is an example of a case sent to Dr. Massry for the repair of an ectropic lower lid. Note the improvement in lid position from  before (left) to after (right) surgery.  Dr. Massry’s practice focuses on revisional (redoing problem cases) surgery.

 

 

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5May/110

Upper and Lower Lid Blepharoplasty

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Cosmetic eyelid surgery (blepharoplasty) can be performed on the upper lids only, lower lids only, or on all four lids (four lid blepharoplasty).  The goal of surgery is to create a natural and youthful surgical result.  This can only be accomplished with a meticulous preoperative examination of the patient and an equally detailed discussion of patient desires and expectations.  When this is done appropriately, the process is satisfying to patient and physician, and the results are excellent.

Below is an example of a before (left) and after (right) surgery photograph of a patient who underwent upper and lower lid blepharoplasty. Note the significant inporvement in appearance.
 

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4May/110

Eyelid Fat Grafting

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Hollowing of the eyelids is a major problem for many patients presenting for eyelid rejuvenation today.  This can occur from aging alone, or also from previous eyelid surgery.  Contemporary thought is that fat around the eyelids is precious and must be preserved when possible.  In the areas of the lids which are prominent (puffy) where there is excess fat; the fat can be moved (repositioned) to areas of hollows or depressions.  It is important to remember that depressions and hollows around the eyes are as common and important to address as is fat prominence.  If this important point is not taken into consideration when performing eyelid surgery - patients will look skeletonized or sunken after the procedure.  This must be avoided.

The way to avoid this is to preserve local eyelid fat and move it around (fat repositioning), or to take fat from other areas of the body (ie. abdomen) and inject (graft) it into the hollows around the eyes.  Eyelid fat grafting is s very specialized and intricate procedure as eyelid anatomy is complex and the skin is thin. Only an expert in eyelid surgery should perform eyelid fat grafting.

Below is an example of lower lid fat grafting to correct hollows (depressions), improve contour, and restore a youthful appearance.  On the left is the before picture and on the right is the after surgery picture.  Note the improvement in lower lid appearance without an incisions (just fat injections).

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